Acute pancreatitis Case reports. Clinical problems. Use of antibiotics? (P 1 & 2) Surgical treatment of AP? (P 3 & 4)

Transcription

1 Case reports Clinical problems Use of antibiotics? (P 1 & 2) Surgical treatment of AP? (P 3 & 4)

2 Case reports Case 1

3 Case 1 Patient KD History M, 63 y Obesity BMI 30.3 kg/m 2 Gallbladder stones No concomitant diseases 1. episode of ABP Time from onset 33.5 h

4 Case 1 Patient KD Lab data & prognostic assessment WBC (G/l) CRP (mg/l) ND RNS (pts) 5 AP-O (pts 0-1-2) KCE (pts) 4

5 Case 1 Patient KD ERCP & CT ERCP (day 0) CBD 5 mm, no stones No ES CT (day 1) Mild inflammatory infiltration close to body and tail of the pancreas and in the left prerenal space, no pancreatic necrosis (BLT C, CTSI 2)

6 Case 1 Patient KD

7 Case reports Case 2

8 Case 2 Patient MK History M, 29 y Overweight BMI 28.5 kg/m 2 Gallbladder stones No concomitant diseases 1. episode of ABP Time from onset 46.5 h

9 Case 2 Patient MK Lab data & prognostic assessment WBC (G/l) CRP (mg/l) RNS (pts) 2 AP-O (pts 0-1-2) KCE (pts) 2

10 Case 2 Patient MK ERCP & CT ERCP (day 0) CBD 12 mm, impacted stone + 4 other stones SE done, stones removed TK (day 1) Moderate inflammatory infiltrations in both prerenal spaces, no pancreatic necrosis, small amount of fluid around the liver and mild bilateral hydrothorax (BLT C, CTSI 2)

11 TK Acute pancreatitis Case 2 Patient MK

12 Case 2 Patient MK

13 Cases 1 & 2 Case 1 - KD Moderate prognosis Case 2 - MK Very good prognosis SIRS (+) Mild overweight / obesity BLT C, no necrosis, CTSI 2 WBC > 15 G/l CRP > 150 mg/l Should antibiotics be administered?

14 Question Who should receive antibiotics? 1. Both 2. Patient 1 3. Patient 2 4. None

15 Case 1 Patient KD Bacteriology Bile - positive Escherichia coli (sensitive to Ciprofloxacin, Imipenem) Blood negative (1x)

16 Case 1 Patient KD

17 Case 2 Patient MK Bacteriology Blood 10 x negative

18 Case 2 Patient MK

19 Case 1 & 2 Wide-spectrum antibiotics were used in both cases No complications acc. to Atlanta criteria Probably mild necrosis of peripancreatic fat Hospital stay 22 days in both cases Course mild / severe?

20 Case reports Case 3

21 Case 3 Patient AK History M, 79 y General condition severe Hypertension 20 y Parkinson s disease? Suspicion of gallstones Probably 20 h from onset of abdominal pain Very severe abdominal pain

22 Case 3 Patient AK OE Dehydration HR 116/min, RR 30/min No peristalsis Rebound tenderness +-

23 Case 3 Patient AK Angio-CT (day 0) No mesenteric ischemia Extensive atheromatosis Extensive inflammatory infiltration of peripancreatic fat, non-enhancement area (up to 1/3) in body and tail BLT C, necrosis < 1/3?, CTSI 4

24 Angio-CT (day 0) Acute pancreatitis Case 3 Patient AK

25 Case 3 Patient AK ERCP (day 1) Extensive swelling of D2 of moderate severity, bluish discoloration of mucosa, severe duodenopathy Papilla very small and tight No deep CBD cannulation despite pre-cut CDB narrow (< 4 mm)

26 Case 3 Patient AK Lab data WBC (G/l) PLTS (G/l) HCT (%) pao2 (mm Hg) Cre (mg/dl) AT III (%) ND - ND 42 CRP ND!

27 Prognostic assessment Acute pancreatitis Case 3 Patient AK RNS (pts) 6 AP-II (pts 0-1-2) (death risk 85%) AP III J (pts 0-1-2) (death risk 67%) KCE (pts) 7 OFS (Bernard, pts 0-2) 1-6 (death risk 85%)

28 CT (day 2) Mild progression BLT E, necrosis < 1/3, CTSI 6 Acute pancreatitis Case 3 Patient AK

29 CT (day 2) Acute pancreatitis Case 3 Patient AK

30 Case 3 Patient AK Clinical course No improvement within 48 hours Rapidly evolving multiorgan failure Patient transferred to ICU Surgical consultation

31 Case reports Case 4

32 Case 4 Patient ML History F, 50 y No concomitant diseases Mild obesity, BMI 31.6 kg/m2 10 months before single episode of biliary colic No gallbladder stones 1. episode of ABP Time from onset 8 h

33 Case 4 Patient ML OE Obesity Jaundice Epigastric tenderness

34 Case 4 Patient ML ERCP (day 0) Duodenum and papilla normal CDB 10 mm, no stones No ES Microscopic bile analysis: CMC+, CaBG+++

35 Case 4 Patient ML Lab data WBC (G/l) HGB (g/dl) ND (d7) pao2 (mm Hg) 73 TP (mg/dl) CRP (mg/l) (d7)

36 Prognostic assessment Acute pancreatitis Case 4 Patient ML RNS (pts) 6 AP-O (pts 0-1-2) AP III J (pts 0-1-2) KCE (pts) 7 OFS (Bernard, pts 0-2) 0-1

37 Case 4 Patient ML CT (day 2) Enlarged pancreatic head, homogenous enhancement, no necrosis Fluid collections at both prerenal spaces, in spleen hilum, between small bowel loops BLT E, CTSI 4

38 Clinical course Acute pancreatitis Case 4 Patient ML Intensive conventional management, antibiotics SIRS symptoms between days 10 and 16 Control CT (d12) progression, CTSI 4 Control CT (d26) progression, no pancreatic necrosis, but extensive necrosis of peripancreatic fat Second period of fever from day 32, WBC i CRP US fluid collection, bacteriology Str. faecalis Surgical consultation (d43)

39 Case 4 Patient ML CT (days 2, 12 i 26)

40 Case 4 Patient ML CT (days 2, 12 i 26)

41 Cases 3 & 4 Case 3 AK Day 3 Sterile necrosis MOF Bad prognosis Case 4 ML Day 43 Infected necrosis No MOF Moderate prognosis Who should be operated on?

42 Question Who should be operated on? 1. Both patients 2. Patient 3 3. Patient 4 4. None

43 Surgery Day 2 of hospitalization Acute pancreatitis Case 3 Patient AK 2000 ml brown fluid in the abdominal cavity Extensive pancreatic necrosis (black pancreas) Necrosectomy. Setonage. Laparostomy Cardiac arrest at the end of the procedure, death Autopsy: Necrosis haemorrhagica pancreatis et telae adiposae. Inflammatio purulenta cum necrosi d. choledochi.

44 Case 4 Patient ML Surgery Day 49 of hospitalization Extensive fat necrosis Abscess (500 ml) in lesser sac Fat necrosis from right iliac fossa to diaphragmatic hiatus Necrosectomy, setonage, laparostomy

45 Case 4 Patient ML Surgery (2) Multiple exchanges of setones (11) days 51 to 68 Wound abscess in the epigastrium 6 drainage procedures from day 103 to 131 Gradual improvement Discharge on day 146

46 Indications for surgery Infected necrosis Local complications of pancreatitis Sterile necrosis

47 Duodenal swelling No swelling Minor swelling, limited to peripapillary area Moderate swelling with extensive involvement of D2 Severe swelling with extensive involvement of D2, bluish discoloration DGE MUSK

48 Duodenal swelling DGE MUSK

49 Duodenal swelling Normal duodenum Deformed duodenal loop D2 deformed and narrowed DGE MUSK

50 Duodenal swelling Edema of submucosal layer Mucosal hyperemia DGE & DPAT MUSK

51 Duodenal swelling Normal duodenum Marked thickening of D2 wall 20 mm DGE & DRAD MUSK, Helimed

52 Duodenal swelling D2 swelling limited to antero-medial wall D2 swelling limited to peripapillary area DGE & DRAD MUSK, Helimed

53 Duodenal swelling Severe swelling with circular D2 involvement; lumen barely visible in the most severe cases DGE & DRAD MUSK, Helimed

54 Duodenal swelling Duodenopathy grade n (851) % N % MLD 40 5% MOD 88 10% SEV 33 4% p Age (y) Sex (% F) BMI (kg/m2) SE failure (%) Marek et al., Gut 2005 (abstract)

55 Duodenal swelling Duodenopathy grade n (851) % N % MLD 40 5% MOD 88 10% SEV 33 4% p CRP max48 mg/l IL-6 max48 pg/ml WBC max48 G/L AP-O cum48 (score) CTSI 72h (score) Marek et al., Gut 2005 (abstract)

56 Duodenal swelling n (851) % N % Duodenopathy grade MLD 40 5% MOD 88 10% SEV 33 4% p % severe % surgery % mortality SGS Marek et al., Gut 2005 (abstract)